APPLICATION FORM CHRONIC MEDICINE BENEFIT 2019

Transcription

1 APPLICATION FORM CHRONIC MEDICINE BENEFIT Medication for all chronic conditions that are covered may be registered telephonically on (doctors and pharmacists only). 2. Alternatively, please complete this form to apply for Chronic Medicine Benefits. One form must be completed per patient. 3. Once the form has been completed, please it to 4. Forms not completed in full will not be processed. 5. Section 1 of the application form must be completed by the member. 6. Sections 2 and 3 are for information purposes only and must not be sent back to us. 7. Sections 4-8 must be completed by your doctor. 8. Approval of any chronic condition and medicine is subject to clinical entry criteria and drug utilisation review. 9. Please attach copies of any reports to support the diagnosis of chronic conditions, where applicable. 1. PATIENT INFORMATION Surname Initials Full Name(s) RSA Identity No. Date of Birth Telephone: Gender (M=Male; F=Female) Home Code No. Cell No. Work Code No. Fax Code No. Address I understand that my application will not be processed if the information on this form is incomplete or the relevant diagnostic results are not provided to Performance Health. I give permission to my doctor to provide Performance Health with my diagnosis and other relevant clinical information to review my application. Patient Signature (unless a minor) Principal Member Signature Date (only if patient is a minor)

2 INSTRUCTION: To be taken to your doctor for information These conditions are reimbursed on all options provided the Clinical Entry Criteria is met as indicated below. 2. CLINICAL ENTRY CRITERIA FOR THE PRESCRIBED MINIMUM BENEFITS (PMB) CHRONIC DISEASES CDL Condition Addison`s Disease Asthma Bipolar Mood Disorder Bronchiectasis Clinical Entry Criteria (please include the ICD 10 code) Diagnosis to be confirmed by an Endocrinologist, Paediatrician or Specialist Physician 1. Diagnosis to be confirmed by a Pulmonologist, Paediatrician or Specialist Physician 2. Diagnostic Lung Function Test (pre- & post-bronchodilator) for children 7 years old and for all adults Diagnosis to be confirmed by a Psychiatrist Diagnosis to be confirmed by a Pulmonologist or Specialist Physician Cardiac Failure New York Heart Association stage required please capture in Section 6 Cardiomyopathy Subtype required please capture in Section 6 Chronic Obstructive Pulmonary Disease (COPD) Chronic Renal Failure Coronary Artery Disease Crohn`s Disease Diabetes Insipidus Diabetes Mellitus Type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia (A & B) HIV/AIDS Hyperlipidaemia Refer to Section 5 Hypertension Refer to Section 4 Hypothyroidism 1. Diagnosis to be confirmed by a Pulmonologist or Specialist Physician 2. Diagnostic Lung Function Test reflecting both pre- and post-bronchodilator FEV1 3. Motivation for oxygen use: FEV1 with oxygen saturation (arterial blood gas) & hours of oxygen needed /day 1. Diagnostic Creatinine Clearance or estimated Glomerular Filtration Rate (egfr) 2. Hb results and Iron studies required when applying for Erythropoietin Report with diagnostic findings required e.g. ECG (exercise/stress), echocardiography, angiography, or details of cardiac event (ACS/MI/PCI/CABG, including date) please use Section 6 to capture detail Diagnosis to be confirmed by a Gastroenterologist, Surgeon or Specialist Physician Diagnosis to be confirmed by an Endocrinologist, Paediatrician or Specialist Physician Fasting Blood Glucose, and either the 2hr OGTT, HbA1c (DCCT) or Random Blood Glucose result are required (laboratory report); motivation required if only one test result provided - please use Section 6 Diagnosis to be confirmed by a Cardiologist or Specialist Physician Diagnosis to be confirmed by a Neurologist, Specialist Physician or Paediatrician, alternatively the seizure history or abnormal EEG report to be provided Diagnosis to be confirmed by an Ophthalmologist 1. Diagnosis to be confirmed by a Specialist Physician or Haematologist 2. Pathology report indicating factor VIII or IX levels Pathology report with positive ELISA result, CD4 + count and Viral load (note that RNA Viral load is not diagnostic, as it is not specific to HIV) 1. Diagnostic Lipogram required Should include Total Cholesterol, LDL, HDL and Triglyceride values 2. Familial Hyperlipidaemia requires an Endocrinologist diagnosis 3. Most recent Lipogram required should the dose increase or medicine change 1. Two Diagnostic BP readings (3 or more months apart) required for newly diagnosed patients, unless diagnostic BP is 160/100 or significant CV risk factors present 2. Patients younger than 30 years must be diagnosed by a Cardiologist Diagnostic Thyroid function test results: TSH and FT4; Thyroid antibody tests in case of sub-clinical results 1. Diagnostic confirmation from a Neurologist or Specialist Physician Multiple Sclerosis Parkinson s Disease Rheumatoid arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis 2. The following information is required when applying for interferon beta / immunomodulators a. MRI reports b. Relapsing-remitting history(clinical presentation and dates) please capture in Section 6 c. Extended Disability Status Score (EDSS) please capture in Section 6 d. Relapses requiring cortisone therapy - please capture in Section 6 Diagnosis confirmation from a Neurologist or Specialist Physician, otherwise the diagnostic motor signs applicable to the patient to be listed in Section 6 1. Diagnosis confirmation from a Rheumatologist, Paediatrician or Specialist Physician 2. Alternatively, supporting pathology report (CRP/ESR and Rheumatoid factor) to be provided and clinical history confirming diagnosis, as well as treatment history, to be captured in Section 6 Diagnosis confirmation from a Psychiatrist Diagnosis confirmation from a Specialist Physician or Rheumatologist Diagnosis to be confirmed by a Gastroenterologist, Specialist Physician or Surgeon

3 INSTRUCTION: To be taken to your doctor for information 3. CLINICAL ENTRY CRITERIA FOR THE ADDITIONAL CHRONIC CONDITIONS (Only Option A eligible) Additional Chronic Condition Acne Allergic rhinitis Alzheimer s Disease Ankylosing Spondylitis Attention Deficit Hyperactivity Disorder (ADHD) Cushing s Disease Cystic Fibrosis Gastro-Oesophageal Reflux Disease (GORD) Gout prophylaxis only Hyperthyroidism Interstitial Fibrosis Iron Deficiency Anaemia Major Depression Meniere`s Disease Migraine Prophylaxis Myasthenia Gravis Osteoporosis Clinical Entry Criteria (please include the ICD 10 code) 1. Diagnosis to be confirmed by a Dermatologist or GP 2. For Roaccutane and its generics the script must be from a Dermatologist Diagnosis to be confirmed by an ENT, Paediatrician, Pulmonologist or Specialist Physician Diagnosis to be confirmed by a Psychiatrist or Neurologist. Mini mental (MMSE) report required. Diagnosis to be confirmed by a Specialist Physician or Rheumatologist Diagnosis to be confirmed by a Paediatrician, Psychiatrist or Neurologist Diagnosis to be confirmed by an Endocrinologist, Specialist Physician or Paediatrician Diagnosis to be confirmed by a Pulmonologist, Paediatrician or Specialist Physician 1. Standard dose PPIs only for 3 months, thereafter only low dose PPIs or H2-antagonists will be considered for maintenance treatment 2. Diagnostic gastroscopy reports required for double dose PPIs, and new / follow-up gastroscopy required for continuation of standard dose PPIs beyond 3 months No colchicine, cortisone, NSAIDs or analgesics will be considered from the Chronic benefit Thyroid Function Tests including TSH and T4 level required 1. Diagnosis to be confirmed by a Pulmonologist or Specialist Physician 2. Lung Function Test results required Diagnostic and most recent laboratory report with FBC and Iron studies required 1. Diagnosis to be confirmed by a GP (adults only) or Psychiatrist 2. Only generic first line therapy (SSRIs or TCAs) will be reimbursed from the GP script 3. Psychiatrist / Paediatric Psychiatrist script required for patients younger than 18 years Diagnosis to be confirmed by an ENT Only preventative therapy will be reimbursed Diagnosis to be confirmed by a Neurologist 1. Diagnosis to be confirmed by a GP, Specialist Physician or Gynaecologist 2. DEXA Bone Mineral Densitometry (BMD) report (& X-ray report were applicable) required 3. Clinical history, including fractures, and risk factors required please capture in Section 6 Peripheral Vascular Disease 1. Diagnosis to be confirmed by a GP, Specialist Physician or Vascular Surgeon 2. For a GP diagnosis a Doppler Ultrasound report is required 3. Ankle-Brachial Index or Rutherford stage required please capture in Section 6 For Information Purposes Only - Do Not send back

4 The section below must be completed by the relevant doctor: 4. APPLICATION FOR HYPERTENSION 1. ICD 10 Code 2. Height (cm) Waist circumference (cm) Weight (kg) 3. Diagnostic BP (prior to drug therapy) i. Date / mmhg ii. Date / mmhg 4. When did the patient commence drug therapy for Hypertension? 5. Current blood pressure / mmhg 6. Please indicate below if there is target organ damage and / or cardiovascular disease: Angina Cardiac Failure CKD/ Microalbuminuria Hypertensive Retinopathy Left Ventricular Hypertrophy Nephropathy / Microalbuminuria Peripheral Vascular Disease Prior CABG Prior Stent / Angioplasty / Angiogram Stroke / TIA Myocardial Infarction 7. Is the patient currently smoking? Yes No 8. Is there a family history of Arteriosclerotic disease? Yes No If yes, please complete table under point 5 of Hyperlipidaemia (Section 5) 9. Please provide clinical information for use of drug classes that are not standard first or second line therapy (any drugs other than ACE-Is, CCBs and thiazides / thiazide-like diuretics) and please provide a motivation if a beta-blocker is prescribed for essential hypertension:

5 The section below must be completed by the relevant doctor: 5. APPLICATION FOR HYPERLIPIDAEMIA 1. Please attach diagnosing lipogram as well as the most recent lipogram 2. ICD 10 Code 3. Height (cm) Weight (kg) 4. Does the patient smoke? Y N 5. Is there a family history of Arteriosclerotic disease? Y N If yes, please complete table below: Mother Father Sister Brother Event details Age at time of event 6. When did the patient commence drug therapy for Hyperlipidaemia? 7. Current blood pressure / mmhg (if not completed in Section 4) 8. Current fasting glucose / mmol / L (Only for Primary Hyperlipidaemia) 9. TSH (Only for Primary Hyperlipidaemia) 10. Does the patient have Familial Hyperlipidaemia (FH)? Y N If yes, please list signs of FH in this patient: 11. Please indicate whether application is for primary or secondary prevention

6 The section below must be completed by the relevant doctor: 6. ADDITIONAL CLINICAL INFORMATION Please refer to Sections 2 and 3 for requirements relating to Clinical Entry Criteria.

7 The sections below must be completed by the relevant doctor: 7. CURRENT MEDICINE DETAILS Please refer to Sections 2 and 3 for information relating to Clinical Entry Criteria. Diagnosis ICD 10 Code Date of Diagnosis Medicine Name and Strength Dosage/ Quantity per month How long has the patient used this medicine Years Months Repeats 8. DOCTOR DETAILS Name BHF Practice Number Speciality Telephone: Work address: Doctor s Signature Date 1. Please ensure all relevant reports and / or tests are included with this application form. 2. For completion of this application form, use claim code Please remember to use the relevant ICD 10 code with the claim. 3. This form only needs to be completed when applying for a new chronic condition. 4. For any changes to the patient s medicine for approved conditions please call